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Are You Getting Paid for Chronic Care Management? Follow These Tips

Do you frequently review labs for patients with uncontrolled diabetes and educate them about self-management? Do you provide medication management support for family members whose loved one has Alzheimer’s disease? Do you provide ongoing support and education for patients with frequent acute exacerbations of chronic obstructive pulmonary disease?

If you answered ‘yes’ to any of these questions, you’re probably performing chronic care management (CCM)—a service for which the Centers for Medicare & Medicaid Services (CMS) began paying in 2015. But are you billing for it?

2017 Reimbursement for Chronic Care Management Services

When documented and coded appropriately, here’s what physicians can expect when reporting chronic care management (CCM). These are the 2017 national average Medicare payment amounts based on the physician fee schedule:

Know When to Report Chronic Care Management

Though there is a laundry list of operational and documentation-related requirements that physicians must fulfill before billing CCM, Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, owner of KGG Coding and Reimbursement Consulting, LLC, in Birmingham, AL, says the biggest challenge is simply trying to determine what patients qualify. Not every patient with a chronic condition needs CCM, she adds.

Per CPT guidelines, patients who receive CCM services must have two or more chronic continuous or episodic health conditions (e.g., heart failure, cancer, chronic kidney disease, or stroke) that a physician anticipates will last at least 12 months or until the patient’s death. These conditions must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

The guidelines don’t provide a list of chronic conditions that would qualify, although Huey says CMS’ Chronic Condition Data Warehouse (CCW) is a helpful resource. The CCW includes 27 chronic conditions that CMS tracks in terms of volume and cost, and physicians can use it as a starting point when thinking about CCM.

“Some physicians would argue that, ‘By virtue of them having one of these conditions, they’re at risk of decline.’ But I really think it’s more of a judgment call that needs to be made,” she adds. “It’s not every patient. Some patients are managed well and have no issues.”

There are also a lot of conditions that are not in the CCW that could potentially qualify for CCM because they put patients at significant risk. Huey cites the examples of Parkinson’s disease, autism and Crohn’s disease.

3 Tips for Billing CCM

The challenge of knowing when to bill for CCM shouldn’t discourage physicians from doing so when it’s appropriate. These tips can help physicians determine what patients may qualify for CCM:

1. Capitalize on each patient’s annual wellness visit.

“This is the time when you’re gathering all of that information about the patient,” says Huey. Use this annual visit to assess social, emotional, mental and physical health-related challenges that may have emerged over the course of the last year. One of the goals of CCM is to address these types of challenges, and the annual wellness visit is a perfect time to identify them, she adds.

2. Document risk in the narrative of the note.

Many physicians simply check off a box next to a diagnosis in the electronic medical record without elaborating on what’s happening with the patient—and why he or she needs CCM services. What are the challenges that each patient faces? Why are they at risk of functional decline, acute exacerbation, decompensation, or death?

3. Examine each clinical scenario carefully.

“You need to look at each individual patient’s circumstances and realize that it’s not just about [reporting] a diagnosis code,” says Huey. “It’s also everything related to the patient’s own self-management of the disease.” Don’t assume that every patient with diabetes, for example, needs CCM. Many can manage the disease on their own, she adds.

Think ‘Compliance’ All the time

Although most denials for CCM are technical in nature (e.g., billing for CCM and transitional care management during the same service period or billing for CCM when another provider has already done so), it’s likely that payers performing retrospective audits will begin to examine physician documentation more closely to see whether CCM services are justified. Adhering to all clinical and technical requirements will help physicians bill for CCM appropriately—and retain the revenue they receive, she adds.

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